The sheer range of diverse and complicated refugee and asylum seeker visa types exemplifies the complexity of Australian health care and health policy for refugees and asylum seekers. This complexity often leads to confusion among refugees, asylum seekers, community workers and health care practitioners alike. Additionally, current health care policy presents numerous grey areas. In particular, problems exist around gaps between the legal and practical applications of these policies; lack of policy coordination between State and Commonwealth governments; asylum seekers' ability to successfully access necessary health care; decisions about granting ASAS; lack of publicly accessible government data; and implications of the new RPBV.
Significant gaps between legal and practical policy implementation and the lack of coordination between State and Commonwealth governments may be best exemplified by the issue of access to public hospitals for asylum seekers. To begin, it is important to distinguish between legal restrictions and de facto
restrictions. Disparities between being eligible to access health care and being able to access health care epitomise these gaps. In other words, asylum seekers with no Medicare can, theoretically, access public hospitals but may not be able to do so because they fear that their lack of income will leave them unable to pay hospital fees. There is growing evidence suggesting that Medicare ineligible asylum seekers have been turned away from hospitals, have not completed their required medical treatment, or have been asked to pay outstanding hospital bills and this is of significant concern [20
Although some State governments have attempted to improve asylum seekers' access to health care and welfare [38
], the Catholic Commission for Justice Development and Peace reports that State governments have failed 'to provide clear instructions to their departments and agencies to protect the human rights of asylum seekers in the areas of housing, health, transport and education' [39
]. Additionally, State and Territory governments do not have clear policies concerning Medicare ineligible asylum seekers. In New South Wales (NSW), for example, an assurance of payment is required before treatment will be provided. If, however, that assurance is not available, then patients will 'receive only the minimum and necessary medical care to stabilise their condition' [1
Strategies and practices for the provision of care to this population also vary widely across public health care services. While a few services provide ease of access to asylum seekers, many CBOs report that the majority deny access or attempt full fee recovery after providing the services. Commonly, access to these services, including waiving of fees, is dependent on long term advocacy from CBOs [19
Other factors, such as English language skills and ability to access transport, also influence asylum seekers' ability to access successfully health care, thereby creating even greater gaps between policy and practice. As mentioned previously, current Commonwealth policy does not provide asylum seekers on Bridging Visas and refugees on TPV access to English language tuition or fee-free interpreting. Studies from the UK indicate that misunderstandings and poor communication between medical practitioners and asylum seekers operate as barriers to appropriate health care [1
]. Clearly, this is also the case for refugees and asylum seekers within Australia, who do not have access to fee-free interpreting services.
Transport is often another major barrier to refugees and asylum seekers attempting to access health care with many lacking the money necessary for public transport or taxis. Could they access a vehicle, many are ineligible for drivers' licences, unless they can read, write and understand English sufficiently to pass the exam.
A key barrier towards improving health policy for refugees and asylum seekers is the difficulty in obtaining clear information from relevant Commonwealth Departments. For example, in relation to ASAS eligibility, it is unclear how DIMIA applies its discretionary powers to extend eligibility to ASAS or similar 'special payments' to some asylum seekers whose cases are at the post-RRT stage. Similarly there is a lack of publicly available government data on several key issues regarding asylum seeker health policy. First, it is unclear how many asylum seekers are living in the community on Bridging Visa E. This makes it difficult for CBOs to assess levels of need and asylum seeker populations. Second, there is currently no procedure for recording asylum seekers' access to health care which has lead to a lack of knowledge to inform policy and practice. Third, there are no available data for analysing the numbers of refugees and asylum seekers using public hospital services and, finally, there are no data on what they are being treated for. These issues, in turn, make it virtually impossible to estimate rates of and reasons for admission. Thus, we are left with case studies and documentation carried out by the already strapped CBOs working in the sector.
The recent introduction of RPBV only complicates these grey areas further. In particular, the RPBV creates disparities between bridging visas, presents significant human rights issues and has the potential to lead to further mental health issues for these asylum seekers. First, the RPBV's provision of Medicare raises significant issues around the levels of health care access for asylum seekers on other types of Bridging Visas. For example, what is the rationale behind the decision to grant Medicare rights to this Bridging Visa, when existing Bridging Visas offer no similar rights? Why has the provision of greater rights under this Bridging Visa not translated to other, similar visa categories? That is, if Medicare has been deemed necessary for these Bridging Visa holders, why has this not been extended to other Bridging Visa holders?
The RPBV also raises great concern about potential denial of human rights. Currently, the RPBV requires asylum seekers to agree in writing that they will cooperate with their removal from Australia when the government deems it is safe to do so. Thus, there is the very real potential for the promise of release from detention to lead to asylum seekers relinquishing their legal rights and future opportunities for visas. The written agreement may also facilitate involuntary return – individuals will have no say about the safety of their return, once the government deems it should happen [40
The RPBV may also have significant effects on the mental health of asylum seekers. There is a growing body of evidence on the negative mental health impacts of detention on asylum seekers [41
]. Releasing these already traumatised individuals into the community without immediate and ongoing access to counselling, and with no definite return date, no guaranteed visa term and no rights of appeal, could lead to further mental health issues, such as depression, feelings of isolation and anxiety.